Overview

The Hospice Clinical Review Manager's primary responsibility is ensuring compliance with local coverage determinants (LCD) in coding and documentation upon Start of Care (SOC) and recertification for hospice patients. The main objective of the role is enhancing the quality of care through effective clinical record review. They are responsible for Hospice Item Set (HIS) review for accuracy, for managing and analyzing the plan of care and ensuring it is in alignment with assessments documented. They review and ensure criteria for coverage is clearly documented and Plan of Care's are coded appropriately for hospice care. This role involves ensuring compliance with regulatory standards related to comprehensive assessment and LCD criteria. They act as a resource to the clinical team and support clinical team members by providing feedback related to LCD, HIS and hospice documentation to support hospice care. This role is responsible for oversight of the Certification for Terminal Illness (CTI) orders clinical management in the EHR, when generating the Plan of Care Order for hospice.
The Hospice Clinical Review Manager is an integral part of the QAPI team and assists in clinical record reviews to assess for quality of care and identify areas of opportunity.

Compensation Range:$98,200.00 - $130,800.00 Annual

• Collects, analyzes, and maintains clinical data related to patient care. • Ensures accurate and timely documentation of patient information in electronic health records (EHR). • Monitors data quality and integrity to support clinical decision-making. • Ensures compliance with HIPAA regulations and other relevant laws governing patient information. • Conducts in real time audits of clinical documentation with emphasis on LCD, HIS and coding and provide feedback to hospice clinicians. • Collaborates with hospice leadership to develop and implement best practices for documentation. • Provides training to clinical staff on the use of LCD’s, POC matching documentation assessment, HIS. • Serves as a resource for team regarding coding, LCD’s and HIS. • Generates reports for leadership related to clinical compliance with LCD’s and HIS demonstrate compliance and performance metrics. • Analyzes clinical data to identify trends, outcomes, and areas for improvement in patient care. • Participates in quality improvement initiatives based on data analysis. • Works closely with interdisciplinary teams to ensure the integration of hospice information set into patient care processes. • Participates in care planning meetings to support data-driven decision-making. • Collaborates internally to ensure timely and appropriate processing of patient care for optional outcomes and scheduling process • Identifies, resolves and/or escalate issues to improve outcomes and efficiency in patient care, clinician work and organizational processes. • Participates in special projects and performs other duties as assigned.

Qualifications

Licenses and Certifications:
Current license to practice as a Registered Nurse in New York State   required
Certified Hospice and Palliative Care Nurse (CHPN) preferred

Education:
Bachelor's Degree in Nursing required

Work Experience:
Minimum of five (5) years of hospice experience required
Certified Hospice and Palliative Care Nurse (CHPN) preferred
ICD-10 coding familiarity required
Strong knowledge of National Government Services (NGS) Local Coverage Determinants (LCD) for hospice required
Proficiency in Home Care Home Base (HCHB) preferred
Strong analytical skills required to be successful in this role required
Excellent communication and training abilities; capable of working collaboratively with clinical staff and management required